Preliminary Care Coordination Infographic
despoint58
5 days ago
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files (3)cf_example_poster_infographic.pdf
cf_example_infographic.pptx
FamilySupportandHomeAssessmentsv5..pdf
cf_example_poster_infographic.pdf
SPECIFIC Reduce A1c Level by 1% in 3 months (ADA)
MEASUREABLE Track daily blood sugar readings ( CDC)
ATTAINABLE This SMART goal is feasible if you have access to the necessary resources and a diabetes management plan.
RELEVANT/TIME BOUND GCM allows for daily monitoring. Patients to log cards and physical activity in the GCM app. The patient will come to the next visit in 3 months for a review.
SMARTGOALSGOALS FOR DIABETES
TYPE-1TYPE-1
Include description of condition and/or relevant starting patient information here
YOUR PARAGRAPH TEXTYOUR PARAGRAPH TEXTYOU
List of Resources Would go here.
cf_example_infographic.pptx
Best Practice
Frequent testing helps maintain optimal levels.
Administering insulin as prescribed by a healthcare provider.
Focus on whole grains, lean proteins, fruits, and vegetables.
Regular exercise improves insulin sensitivity.
Blood Sugar Monitoring
Insulin Therapy
Diet
Physical Activity
Type 1 Diabetes
Disease Description
CDC
ADA
NIDDK
Clinical Diabetes Journal
Citation
Citation
Citation
Citation
SMART goals
Reduce A1c Level by 1% in 3 months (ADA)
Track daily blood sugar readings ( CDC)
Specific
Measurable
Attainable
Realistic and Time-Bound
Type 1 Diabetes
Include psychosocial, physical, and cultural considerations here:
S
M
A
R/T
X
X
X
X
This SMART goal is feasible if you have access to the necessary resources and a diabetes management plan.
GCM allows for daily monitoring. Patients to log cards and physical activity in the GCM app. The patient will come to the next visit in 3 months for a review.
Community
Diabetes Management program
Transportation to visit
Online Support groups
Technology
Type 1 Diabetes
Include psychosocial, physical, and cultural considerations here
Resource
Resource
Resouce
Resource
Evidence in APA formatting
Evidence in APA formatting
Evidence in APA formatting
Evidence in APA formatting
3
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FamilySupportandHomeAssessmentsv5..pdf
Sentinel City® Student Report
Luis Gonzalez AutoGen_03699f5a-148f-4957- bb09- [email protected]
Capella University-2147311862
7/19/2026
7/23/2026
Name:
ID:
First Access:
Last Access:
Email:
Tenant:
10 hrs 58 mins10 hrs 53 mins5 mins
Total Time SpentTime in AssessmentsTime in City
CARE PLAN FAMILY SUPPORT ASSESSMENT
100%Progress: Time Spent: 2 hrs 52 mins
RelationshipName
selfCandice
RelationshipName
3Fair
Total Household Occupants (Include Client)Ability to Pay Other Monthly Bills
FairRent
Ability to Pay Rent / MortgageRent / Own
YesGovernment aid
Child SupportOther Sources of Income
9,984Employed
Total Annual Income from EmployerEmployment Status
High School Grad
Highest Level of Education Completed
EnglishUnknown
Primary Language Spoken At HomeReligious Preference
Single26White / Non-Hispanic
Marital StatusAgeRace/Ethnicity
Candice Conway
Client Full Name
07/21/2026Luis Gonzalez
DateInterviewer Completing this Assessment
ADULTS IN THE HOME
FINANCIAL
GENERAL FAMILY INFORMATION
Page 1 of 9Thursday, July 23, 2026
Sentinel City® Student Report
Luis Gonzalez AutoGen_03699f5a-148f-4957- bb09- [email protected]
Capella University-2147311862
7/19/2026
7/23/2026
Name:
ID:
First Access:
Last Access:
Email:
Tenant:
10 hrs 58 mins10 hrs 53 mins5 mins
Total Time SpentTime in AssessmentsTime in City
Brandi's fatherJessi
RelationshipName
Page 2 of 9Thursday, July 23, 2026
Sentinel City® Student Report
Luis Gonzalez AutoGen_03699f5a-148f-4957- bb09- [email protected]
Capella University-2147311862
7/19/2026
7/23/2026
Name:
ID:
First Access:
Last Access:
Email:
Tenant:
10 hrs 58 mins10 hrs 53 mins5 mins
Total Time SpentTime in AssessmentsTime in City
Lot of conserns about Jessi. Canice doesn't want to leave her kids with hime anymore because of his short temper. Lack of support from newborn father
General Childcare Arrangements / Concerns
Child Support
Jessi won't probably be involved in child's careBottle feed
Information about child's fatherPlans to breastfeed or bottle feed
Noabout 24
Prenatal care?How many weeks?
Yes
Is client currently pregnant?
Female2Brandi
GenderAgeChild
NoYes
Are there medical issues with this child?Are Immunizations up to date for this child?
Jessi works at his dad's liquor store in Industrial Heights.He has short temper and consumes drugs and alcohol
Information about child's father
Child Support
Child Support
His father is Randy. He was locked up for domestic abuse for a couple of years. Candice thinks he's out now on work-release, but he must be in a different city
Information about child's father
YesYes
Are there medical issues with this child?Are Immunizations up to date for this child?
Male8Brayden
GenderAgeChild
CHILDREN IN THE HOME
Page 3 of 9Thursday, July 23, 2026
Sentinel City® Student Report
Luis Gonzalez AutoGen_03699f5a-148f-4957- bb09- [email protected]
Capella University-2147311862
7/19/2026
7/23/2026
Name:
ID:
First Access:
Last Access:
Email:
Tenant:
10 hrs 58 mins10 hrs 53 mins5 mins
Total Time SpentTime in AssessmentsTime in City
Uncertain when she goes back to work
Newborn care
Page 4 of 9Thursday, July 23, 2026
Sentinel City® Student Report
Luis Gonzalez AutoGen_03699f5a-148f-4957- bb09- [email protected]
Capella University-2147311862
7/19/2026
7/23/2026
Name:
ID:
First Access:
Last Access:
Email:
Tenant:
10 hrs 58 mins10 hrs 53 mins5 mins
Total Time SpentTime in AssessmentsTime in City
Other environmental, health, and safety hazard identified on the scenario also impact the life quality of this family
Other Notes
Excessive sodium, high added sugar, lack of fiber and micronutrients like essential vitamins as well as unhealthy fat and additives from frozen food and sodas
Frozen food. Milk and cereal for children
At Joe's Grocery across the street
Nutrition ConcernsFoodGrocery
Yes
Concerns about physical, emotional, or behavioral problems with any of the children?
Yes
Does the client have concerns about harming their children?
Yes
Does the client have concerns about someone threatening or physically hurting them?
Yes
Does the client need to get away from an abusive relationship or harmful situation?
Yes
Is client currently a victim of domestic violence?
Yes
Has client ever been a victim of domestic violence?
NoYes
Abuse of Prescription MedicationsAlcohol Use
YesYes
Use of Illegal SubstancesSmoker
OTHER
SUBSTANCES
Page 5 of 9Thursday, July 23, 2026
Sentinel City® Student Report
Luis Gonzalez AutoGen_03699f5a-148f-4957- bb09- [email protected]
Capella University-2147311862
7/19/2026
7/23/2026
Name:
ID:
First Access:
Last Access:
Email:
Tenant:
10 hrs 58 mins10 hrs 53 mins5 mins
Total Time SpentTime in AssessmentsTime in City
APARTMENT ASSESSMENT 1 hr 9 minsTime Spent:100%Progress:
Care PlanRationaleNameCategory
Educate the patient and residents on strictly moving all smoking activities outdoor to eliminate active secondhand smoke accumulation. Instruct the patient to open windows and utilize exhaust fans to clear airborne toxins while explaining that ventilation alone does not fully remove third-hand residue. Recommend washing hard surfaces with detergent and hot water to break down embedded tar and resinated chemicals.
Indoor smoking represents not only an immediate health but also an environmental and safety risk. Resinated chemicals permanently embed into surfaces and ventilation networks maintaining high pollution levels. Toxins trigger acute respiratory distress, cardiovascular strain, and long term cancer risk for all residents. Besides, dropped embers present a constant fire hazard while tar physically degrades the structure and assests
Smoking cigarattes
Environmental
Instruct the patient to discard expired leftovers and store all remaining food items in airtags, sealed plastic or glass containers. Guide the patient to wipe down kitchen counters daily, clean up spills immediately and remove garbage from living space every evening. Assist the patient in contacting landlord services or a professional exterminator to address the roach infestation safely
May cause intestinal disease transmission as well as respiratory and psychological issues due to unsanitary living space. They may also cause stain and property damage
Leftovers and roaches
Environmental
Page 6 of 9Thursday, July 23, 2026
Sentinel City® Student Report
Luis Gonzalez AutoGen_03699f5a-148f-4957- bb09- [email protected]
Capella University-2147311862
7/19/2026
7/23/2026
Name:
ID:
First Access:
Last Access:
Email:
Tenant:
10 hrs 58 mins10 hrs 53 mins5 mins
Total Time SpentTime in AssessmentsTime in City
See above
Indoor smoking represents not only an immediate health but also an environmental and safety risk. Resinated chemicals permanently embed into surfaces and ventilation networks maintaining high pollution levels. Toxins trigger acute respiratory distress, cardiovascular strain, and long term cancer risk for all residents. Besides, dropped embers present a constant fire hazard while tar physically degrades the structure and assests
Smoking cigarattes
Health
Educate the resident on how standing, unattended organic garbage acts as breeding ground for harmful bacteria, mold spores, and airborne foul odors. Explain the direct correlation between left-out trash bags and attracting disease-carrying insects or rodents into the living space. Help the resident to set up a structured household routine, such as taking trash to the main dumpster or outside bin every evening before bed
Trash bag left unattended can create foul odors, attrackt pests, and create breeding grounds for harmful bacterias
Trash bag left unattended
Health
Intruct the caregiver to empty the bucket of water immediately to eliminate the active, proximal drowning hazard. Establish a household rule requiring all cleaning bucket or large open containers to be stored inverted (upside down) in a locked closet or high shelf immediately after use
An unattended bucket of water puts the kids on a risk of drowning. The kids high levels of gravity and large heads make them prone to losing their balance and toppling headfirst into containers
Drowning hazardSafety
Direct immediate removal of all glass bottles from the floor area to clear walkways and prevent immediate lacerations or falls. Discuss how fragile glass can shatter easily which present severe cutting hazards for adults and children. Assist the patient in designating a safe area to store the glass bottles.
Can cause cutting injuries to adult and children if shuttered. Risk for slips, trips, and falls
Glass bottles on floor
Safety
Page 7 of 9Thursday, July 23, 2026
Sentinel City® Student Report
Luis Gonzalez AutoGen_03699f5a-148f-4957- bb09- [email protected]
Capella University-2147311862
7/19/2026
7/23/2026
Name:
ID:
First Access:
Last Access:
Email:
Tenant:
10 hrs 58 mins10 hrs 53 mins5 mins
Total Time SpentTime in AssessmentsTime in City
NURSING DIAGNOSIS 6 hrs 52 minsTime Spent:100%Progress:
Evidence - Based Rationale(s)Nursing Actions
1- Maternal Outcome: The patient will remain free of preventable pregnancy-related complications (e.g. severe preeclampsia, injury from falls, or unchecked infections) throughout the gestational period.�Fetal Outcome: The fetus will maintain a reassuring status as evidenced by normal feta heart rate (FHR) patterns (HR 110-160 bpm) and a healthy reactive non-stress test (NST) by week 28. 2- Immediate Safety Outcome: The patient will formulate a comprehensive, actionable safety plan and identify a secure emergency shelter location within 24 hours. Short-Term Outcome: The patient will disclose immediate dangers and escalation of violence to the healthcare team and accept referrals to local IPV advocates and social services within 48 hours. Long-Term Outcome: By the time of delivery, the patient and infant will reside in a safe environment (either via secure shelter, independent housing, or monitored family placement) free from violence with active links to substance rehabilitation and economic aid.
Expected Outcome
Statement: 1- Risk for Maternal and Fetal Injury among pregnant community residents related to innadequate regional prenatal care accessibility, environmental hazard exposure, and/or socioeconomic stressors. 2- Dysfuntional Family Processes within the community setting related to substance use disorder, financial deprivation, and intimate partner violence, as evidenced by chronic domestic conflict, physical safety hazards to the pregnant patient/fetus and fractured support systems.
Community Health Nursing Diagnosis
Dysfunctional Family Processes
Risk for Maternal and Fetal Injury
Nursing Diagnosis
1- The nurse will evaluate goal achievement by reviewing fetal kick counts, blood pressure trends, serial ultrasound metrics, and lab data (such as urine protein and blood glucose) at each regular prenatal visit. 2- The community nurse will evaluate safety metrics through unannounced or carefully coordinated home visits (when safe), private face-to-face interviews away from the partner and collaboration with case managers, victim advocates, and law enforcement if necessary.
How will the nurse evaluate if goals/outcomes are achieved?
ANALYSIS
PLANNING
IMPLEMENTATION
Page 8 of 9Thursday, July 23, 2026
Sentinel City® Student Report
Luis Gonzalez AutoGen_03699f5a-148f-4957- bb09- [email protected]
Capella University-2147311862
7/19/2026
7/23/2026
Name:
ID:
First Access:
Last Access:
Email:
Tenant:
10 hrs 58 mins10 hrs 53 mins5 mins
Total Time SpentTime in AssessmentsTime in City
1- Early detection of hypertension and proteinuria is critical for managing preeclampsia, which directly threatens placental perfusion and maternal safety.2 - A drop in fetal movement or a non-reactive NST can point to placental insufficiency or fetal hypoxia, signaling a need for immediate intervention.3- Hormonal changes induce joint laxity, shifting the maternal center of gravity and raising the risk of falls and physical injury. Excessive physical strain after mid-pregnancy is statiscally linked to an increase in preterm birth risks. 4- Screening in the presence of the perpetrator significantly increases the risk of immediate retaliation and severe harm to the patient. 5- Having a pre-established, hidden safety strategy reduces panic and reduces response time when a crisis escalate, increasing likelihood of a successful escape. 6- Addressing substance dependency requires specialized care that accounts for IPV-related trauma; alleviating economic strain reduces a major trigger for household stress and removes barriers to leaving an abusive.
1- Check blood pressure and screen for protein in the urine at each check-up.2- Teach the mother to perform daily fetal kick counts and schedule clinical NSTs as indicated for high-risk profiles. 3- Instruct the patient on safe body mechanics, modifying physical tasks over 20 weeks, avoiding strenuous lifting, and minimizing enviromental risks. 4- Conduct private screening and universal IPV assessments at every encounter and only when she is entirely alone.5- Collaboratively develop a personal safety plan.6- Initiate multidisciplinary referrals for substance use and financial aid.
EVALUATION
Goal met: The patient demonstrated a stable blood pressure below 140/90 mmHg, urine test remained negative for protein, and fetus maintained a reactive NST with normal growth tracking. Goal met (Safety component): The patient successfully completed a personalized safety plan, memorized a domestic violence hotline number, and safely hid an emergency bag at a trusted neighbor's home. Goal met (Systemic component): The family unit remains highly unstable. The partner refused substance use rehabilitation, but the patient has completed intake paperwork for emergency maternal housing and transitional financial assistance. Continued close monitoring by community health systems is required.
Page 9 of 9Thursday, July 23, 2026
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